Why would my Insurance Company deny my claim?  

Often people are surprised and feel betrayed that their insurance company would deny them for the very coverage that was paid for.  The unfortunate reality is that this happens all too often and the truth is insurance companies care more about paying as little as possible on claims than they do taking care of their customers.

Who decides whether to accept or deny my claim?

An employee of the insurance company called an insurance adjuster or claims adjuster usually decides whether or not to accept or deny insurance claims.  While these adjusters act like they’re on your side, their main goal is to pay out as little as possible for insurance claims. 

What can I do to protect myself from insurance or claim adjusters?

Insurance or claim adjusters often only want to communicate by phone as there is no record of what is being said.  Always try to have them communicate in emails or writing what they tell you about your insurance coverage.  If they won’t, take your own notes with dates and times of your conversations with the insurance adjuster or claim adjuster.  

Should I stop working if my injury or illness is making it difficult to do my job?

The answer as to whether or not you should continue working is something you will need to decide in discussions with your treating doctors.  If your treating doctors think you should stop working, then you should probably listen to their opinion.  If you keep trying to work you can cause further injury to yourself only making the situation worse.  Also, some disability policies require you to be “actively working” at the time of your disability in order to qualify for benefits.  This is usually defined at a minimum number of working hours in your insurance policy.  If your injury or illness causes you to reduce your hours of work over a period of time, by the time you finally decide to apply for disability, you may not be working enough hours to be considered “actively working” under the terms of your policy.   

If I’m currently on Long-Term Disability when should I be concerned?

If you’re currently on Long Term Disability or receiving other ongoing disability benefits, beware when your claim adjuster starts asking for specific updates, or for you to write a diary of your day to day life.  This is not information they need unless they’re evaluating whether or not you still qualify for disability payments.  

How often do I have to see my Doctor if I’m on Disability?

Almost all insurance policies for disability require you to be under the care of a doctor.  This can be challenging in a time where finding a general practitioner doctor is difficult and many walk-in doctors do not want to take on what they might see as a burdensome patient.  What happens if you are being treated by a nurse-practitioner and not an actual doctor?  How often must you see your doctor to be under their “care”?  These are ill defined terms however, like most vague contractual terms, this usually works out to the disabled person’s benefit at the end of the day.

Can I travel or move out of province while on long-term disability?

Some insurance policies have specific provisions dealing with travelling or moving out of province.  Even if your policy does not have a specific provision for this the best approach is to simply contact your insurer and let them know of your intention to travel out of province or move out of province.  So long as your doctor supports the trip/move and the insurance company is aware there should not be a problem.

What is a Transferable Skills Analysis?

A Transferable Skills Analysis (TSA) is an assessment of your skills from previous employment that could be used to in another job in an attempt to evaluate an individual’s ability to become employable.  Quite often insurance companies will use these assessments to find alternative employment for disabled people when they have been on disability for close to two years after which they will need to be disabled from any occupation to continue with their long-term disability.  Often insurance companies will identify occupations which are practically not workable but use those occupations as a rationale to deny further long-term disability coverage.

My Insurance Company sent me a questionnaire to fill out, is that normal? 

Generally speaking, when you get a questionnaire to fill out about your day to day living and current capabilities, what the insurance company is really trying to do is gather evidence to support denying ongoing benefits.  They will attempt to use medical documentation and video surveillance to contradict the answers you give in a questionnaire as the basis for denying benefits. 

Do insurance companies use private eyes?

When insurance companies are trying to find ways to cut-off active insurance claims they will often hire private eyes or individuals called Independent Adjusters, to follow people and record what they’re doing in hopes of using the surveillance footage to find an excuse to cut-off an active disability claim.  Often they try to use the surveillance footage to contradict answers you’ve already given them in questionnaires.

What if my Insurance Company sends me to a medical evaluation?

If you’re currently on Long Term Disability or receiving other ongoing disability benefits and your insurance company wants you to be evaluated by a medical practitioner they hire, this is a good indication that they’re looking for a reason to cut-off your claim.  Insurance companies hire doctors to do Independent Medical Evaluations (IMEs) to find a way to deny legitimate disability claims.

What’s the difference between Private and Group Insurance Plans?

Private Insurance plans are taken out by an individual, while Group Insurance Plans are offered by employers.  Because Group Plans spread the insurance risk among many people, they are usually less expensive than Private Plans.

What is an Insurance Policy Rider?

An insurance policy rider is extra coverage and benefits a person can choose to purchase to add on to their insurance policy.  These are sometimes called endorsements. 

What is a COLA Rider?

A COLA rider is a provision found in Long-Term Disability policies that allows for benefits to be adjusted for inflation.  COLA stands for Cost of Living Adjustments and COLA rider’s are usually based on a fixed percent or tied to the Consumer Price Index.

What is a Partial Disability Rider?

A partial disability rider is a provision found in Long-Term Disability policies that allows for payment of partial disability benefits when the person is not totally disabled.  This occurs in situations where someone is working, but their disability is preventing them from working to their full capacity/full time.  

Partial disability riders are usually only found in the more costly private policies.

What is an Own Occupation Rider?

An Own Occupation Rider is a provision found Long-Term Disability policies which provides for benefit payments if you are disabled from your own occupation, even if you start working in a different occupation. 

Own Occupation Riders are usually only found in the more costly private policies.

What is a Future Increase Option Rider?

A future increase option rider allows a person to increase their coverage in the future as their income rises.  These riders are useful for business owners who are just starting out and hope to earn more as their business grows.

Future Increase Option Riders are usually only found in the more costly private policies.

How long are disability benefits paid for?

Short-term disability benefits are paid for a specific amount of time which is set out in the insurance policy. Usually this time frame ranges from 15 weeks to up to a year, however each case is different.

Long-term disability benefits timelines are also governed by the wording of the insurance policy, with most policies continuing until the insured reaches 65 years of age. There are some policies however that have limits, which can be 2 to 5 years or any other amount agreed to, and others which allow you to pay a premium to continue coverage beyond 65 years of age, which usually have what is called a lifetime benefit rider.

As with most things involving your insurance coverage it will come down to the precise wording of your contract and how the Courts will interpret them. An experienced lawyer can help you understand your rights.

What’s the difference between being disabled from your own occupation vs. any occupation?

Almost all disability contracts have two different standards of disability that someone must suffer from to meet the terms of the policy.  Usually for the first 1 to 2 years of disability you have to be disabled from performing the duties of the job you have at the time you are disabled.  This is known as the own occupation period.  After this period most policies require you to be disabled from any occupation available to you within certain parameters.  This is a much higher standard and usually when insurance companies deny serious long-term claims.  

Will my Long-Term Disability payments affect my pension?

This depends.  Surprisingly, under some Long-Term Disability employee group or union plans, a disabled individual can continue to accrue pensionable amounts as if you were still actively working.  This is dependent on the particular plan and will require the review of someone with legal expertise to be certain.

Do I have to apply for Canada Pension Plan (CPP) Disability?

Many Long-Term disability contracts will require you to apply for Canada Pension Plan (CPP) Disability.  This is because if you are found to be disabled by the definition of Canada Pension Plan (CPP) Disability, any benefits you are owed under your Long-Term Disability policy will be reduced by any benefits received from Canada Pension Plan (CPP) Disability.

Is it difficult to qualify for Canada Pension Plan (CPP) Disability?

The bar for qualifying for Canada Pension Plan (CPP) Disability is a high one.  Your disability must be severe and prolonged in order to qualify.  On top of this you must have contributed to CPP throughout your employment prior to becoming disabled.

You can apply for Canada Pension Plan (CPP) Disability here: https://www.canada.ca/en/services/benefits/publicpensions/cpp/cpp-disability-benefit/apply.html

Will Canada Pension Plan (CPP) Disability payments reduce my Canada Pension Plan (CPP) Pension payments?

Likely not, and more often than not, if there is any effect it will increase your CPP Pension payments, as your period of disability will cause CPP do change how they calculate your CPP Pension entitlements. 

Are Canada Pension Plan (CPP) Disability Benefits taxable?

Yes, unlike some Long-Term disability benefits Canada Pension Plan (CPP) Disability benefits are taxable as if they were income.

What is the Disability Tax Credit?

The Disability Tax Credit is a tax credit that is available for disabled individuals who meet the criteria of suffering from a severe and prolonged impairment in physical or mental functioning that results in a marked restriction.

Consideration is given to your ability to walk, see, hear, speak, undertake daily tasks of living, as well as other issues to determine if you suffer from a “marked restriction”.

You can apply for the Disability Tax Credit here: https://www.canada.ca/en/revenue-agency/services/tax/individuals/segments/tax-credits-deductions-persons-disabilities/information-medical-practitioners/eligibility-criteria-disability-tax-credit.html

Are there any other Disability Benefits available to me?

That depends on which province you reside in.  In British Columbia there is the Persons With Disability (PWD) benefit.  In order to obtain the Persons With Disability (PWD) benefit you must meet the criteria of being 18 years old, with a severe mental or physical impairment that is expected to continue for more than 2 years, be significantly restricted in your ability to perform the tasks of daily living and require assistance from another person/device/animal on a day to day basis.

There are certain asset and income restrictions you must meet in order to qualify for Persons With Disability (PWD) benefit.

You can apply for the Persons With Disability (PWD) benefit here: https://www2.gov.bc.ca/gov/content/family-social-supports/services-for-people-with-disabilities/disability-assistance#apply

Can I hire a lawyer if I’m part of a union?

Often you can hire a lawyer if you are unionized, but it will require a lawyer’s examination of the policy to ensure this is the case.

What’s the difference between a Group Life Insurance Plan and a Private Life Insurance Plan?

Much like with disability insurance plans, the main difference between group life insurance policies and private life insurance plan, is that for a private plan you will have do undergo medical underwriting.  This is not necessarily so for all group life insurance plans.

What is the difference between Term Life Insurance and Permanent Life Insurance? 

Term life insurance is a life insurance policy for a set term, usually 10-30 years.  The premiums are usually more affordable; however term policies do not pay out a cash value to the policy holder.

Permanent life insurance has more costly premiums but can pay out a cash value to the policy holder during the policy’s life, as well as to beneficiaries upon the death of a policy holder.  The most common permanent life insurance policies are Whole or Universal life policies.

Why would an Insurer deny paying out Life Insurance benefits?

There are many reasons an insurer may deny paying out life insurance benefits.  The most common of these are if the insurer says that the cause of death was specifically excluded from coverage in the life  insurance policy or that the policy holder misrepresented material facts to the insurer in their application for life insurance coverage.

What is a “Contestability Period”?

In the context of life insurance, if a person dies within what is called the “contestability period”, (usually the first year or two after entering into the life insurance policy), then the insurance company has a much broader discretion to deny paying out life insurance benefits.  Quite often when life insurance benefits are claimed within the contestability period the insurance company fights hard against paying out any benefits.

Can an Insurance Company Deny Life Insurance Benefits for Drugs and Alcohol?

While it depends on the policy, some life insurance policies do have provisions which specifically exclude claims if the policy holder dies due to drugs or alcohol. A careful review of the life insurance policy by someone with legal expertise can help.    

Can an Insurance Company Deny Life Insurance Benefits for Suicide?

Again, it depends on the policy.  Some life insurance policies do have provisions which specifically exclude claims resulting from a suicide.  A careful review of the life insurance policy by someone with legal expertise can help.  

What can I do if my Insurance Claim is Denied?

The lawyers at Taylor & Blair LLP can help denied insurance claims.  If your insurance claim is for long term disability, there are steps you can take that will also help.  These include applying for Canadian Pension Plan (CPP) disability or Provincial Persons With Disability (PWD) benefits. 

What if my Insurance Company says I can appeal their decision?

While there is often an option to appeal your insurance company’s decision internally, usually this is not only a waste of effort but a waste of time and your time is not unlimited.  Once a claim is denied initially there is a limited amount of time in which you have to start a lawsuit to get your benefits or you can be statute barred from doing so.  Often appeals are just the insurance company’s way to make you waste this time.

What am I entitled to legally if my insurance claim is unfairly denied?

If your claim proceeds to trial, the law states that all a judge can do is order your insurance company to pay you any amounts owed to the date of the judgment and that it must continue to make payments pursuant to the terms of your insurance contract.

What if I don’t want to continue with my Insurance Company after they denied me coverage?

While a judge can only make your insurance company pay you the amounts owed to date and that the insurance company must continue to make payments pursuant to your insurance contract, many people want nothing to do with their insurance company after an unfair denial.  Due to this, many cases are settled out of court for a lump-sum settlement recognizing past payments owed as well as future payments. 

How much is my claim worth?

This will depend on the facts of your case and the specific wording of the insurance policy.  Insurance policies contain many terms and conditions that an experienced lawyer can help you understand.

How long will it take for my claim to settle?

While it may be shocking many claims can take up to a year if not longer to settle.  However each case is specific and some can resolve much quicker than this.  

What is an insurance broker?

An insurance broker represents someone who is or wants to be covered by an insurance policy and deals with the insurance company on that person or company’s behalf as their representative.  An insurance agent represents the insurance company and insurance brokers represent the insured/those seeking insurance.

What if an insurance broker gave me bad advice?

Insurance brokers have a professional obligation to their clients and if your insurance does not cover you because something your insurance broker did wrong or failed to do, you can sue them to recover what you should have received under your insurance.

Are there time frames that I need to be aware of?

Yes, insurance contacts can contain time limits you need to be aware of.  Experienced lawyers can help you understand these.

Are there any other resources to help me navigate my disability?

In British Columbia the group Disability Alliance BC has been helping people with disabilities for years.  They can assist with applying for disability benefits, filing taxes, ensuring your finances are arranged so as not to interfere with disability benefits, as well as creating all kinds of useful programs to assist those suffering from a disability.

Alliance BC can be found here: https://disabilityalliancebc.org/

The information above is not intended to be legal advice. These FAQs are available for educational purposes only to provide general information and not specific legal advice.